151. Despite high-profile media interest and coverage, there is a lack of hard research evidence on the role and impact of medical tourism. Whilst there is an increasing amount written on the subject of medical tourism, such material is hardly ever evidence-based. In light of this, our broad review outlines key health policy considerations, and draws attention to significant gaps in the research evidence. In order to make sense of the diversity of material and the gaps in extant knowledge, it is worth framing the conclusions and recommendations in terms of Frenk‘s (1994) framework for health policy analysis. This hierarchical framework presents four levels within any health system: systemic (regulation and finance), programmatic (system priorities), organisational (service management) and instrumental (clinical interface with patients).
System issues
152. Key issues at this level relate to the finance and regulation of medical tourism. Despite concerns generated by the current financial crisis, there is no sign that economic liberalization is slowing down. As the trading opportunities in other sectors become exhausted, as experience within services trade generally expands, and as the financial climate stabilises, countries will increasingly look to the opportunities that international trade in services has to offer. For importing services, this will centre on cost, quality and timeliness. For exporting services, this will centre on technology transfer, skill enhancements and foreign income.
153. At present, medical tourism is driven by commercial interests lying outside of organised and state-run health policy-making and delivery. Are there possibilities to bring it more within the remit of domestic policy competency, involving for example third-party payers sending patients overseas? Given the heavily ‗politicized‘ nature of health care in all countries (even those with substantial private health care sectors), there will also be concerns about the threats this poses, including aspects related to brain drain, quality of care and equity. The Crisp Report (2007), commissioned to look at how UK experience and expertise in health could be used to best effect to help improve health in developing countries, argues that by engaging in country-level agreements, and drawing up Memorandum of Understandings between two countries, international recruitment of health professionals can be done ethically and based on a
‗twinning‘ arrangement of reciprocal movement and benefit. If an agreement is achieved to send patients abroad on a more bi-lateral basis, then this may open channels for other agreements such as these, which can then combine international recruitment with training and work experience programmes to address brain drain issues in the importing country. If such a route were taken, this would effectively be a form of outsourcing, with such agreement typically following the well-worn tracks of medical tourist mobility. At this point medical tourism would begin to merge into other forms of patient mobility (EU-cross border care and state-sponsored outsourcing).
154. Countries continue to evaluate their positions on trade liberalization in health, as part of wider bi-lateral, regional and multilateral trade agreements. The latter especially has been the focus of debate, centred on the World Trade Organization‘s General Agreement on Trade in Services (Blouin et al., 2006).
However, there is widespread recognition that the trade agenda (in services generally, and health specifically) is increasingly pursued at the regional or bi-lateral levels (Smith et al., 2009a). Not only have multi-lateral trade negotiations ‗stalled‘ with the ongoing Doha round of WTO trade negotiations, but neighbouring countries often have similar culture, language and economic systems, as well as shorter
travel times, facilitating engagement in trade relations. As a result, trading blocs, such as the European Union (EU) or the Association of South East Asian Nations (ASEAN) have developed, where a significant proportion of international trade takes place. Additionally, many countries bypass the GATS system and engage in direct bi-lateral trade agreements (Smith et al., 2009a). Could this development be broadened to include medical tourist exchanges with countries where travel distance are longer, culture and language less familiar, but where cost savings to the public purse are more apparent?
155. This is an important shift in the dialogue, as greater bi-lateral and regional trade may reduce many of the concerns expressed over health services trade, and offer greater benefits. For instance, it may result in greater quality assurance, as well as better litigation procedures. However, much of the research evidence, anecdote and opinion on trade in health services remain focussed on this multi-lateral perspective. It is important, therefore, to explore bi-lateral trade in more detail, and to assess how it compares to multi-lateral trade. Such a focus would move discussion from the level of global medical tourism to more specific bilateral exchanges – for particular treatments, under specific quality-assured conditions (Smith et al., 2011c).
156. Beyond the national level, medical tourism raises questions for trans-national and global structures and processes. How, indeed if at all, should the medical tourism industry be best regulated, and where is intervention most likely to be effective? There is currently a lack of agreed international standards for assessing and ensuring quality and safety of medical tourism providers and health professionals, and no obligation for them to ensure quality and safety other than an ethical one. Currently, there is no universal
―official agency/group‖, such as the United Nations, the World Health Organization, the World Tourism Organization or the World Trade Organization, engaged in either the delivery of accreditation, the co-ordination of delivery of accreditation, or licensing or studying the existing schemes that deliver accreditation. There is a range of possible solutions (both national and transnational) ranging from interventions that provide more information (although by whom and at what points is not clear); those that restrict choice of potential consumers (either directly prohibited or through discouragement); or attempts to restrict supply (whether approving or licensing providers or intermediaries). There are also interventions that may aim to offer consumer protection around poor-quality treatments which could involve encouraging independent holistic accreditation by recognised schemes, advising that clinicians responsible for delivering services take out personal medical indemnity which would compensate their patients in the event of problems occurring as a consequence of their seeking healthcare, or requiring medical tourists to take out insurance coverage (Cohen, 2010). Source health systems may attempt to shift risk onto individual medical tourists, for example with disclaimers to prevent medical tourists from seeking to rectify poor outcomes at cost to the public purse.
Programme issues
157. What are the programme priorities surrounding medical tourism for both source and destination countries? As outlined, medical tourist choice may lead to externalities at the system and programme level.
Costs may result from overseas cosmetic surgery or dental work that requires subsequent treatment within home countries. There are few case reports or studies of these aspects and the scale of any problem is not clear. Large numbers of medical tourists will also impact on the source country‘s own health system, because outflows reduce both revenue and support for local services. Patients who circumvent waiting times make access and equity for the wider population more problematic. Opportunities for financial benefit from medical tourism include potentially exerting competitive pressure on systems importing health care and may help drive down the costs and prices offered in domestic systems, or relaxing legal restictions in order to stimulate domestic provision of treatments.
158. Most countries that engage in delivering care to medical tourists do so to increase their level of direct foreign exchange earnings. Some countries may promote health services in order to develop facilities
to better serve local patients, although the possibility of resources being diverted from the domestic population and invested into private hospitals and away from rural areas remains a potential dysfunctional outcome. Similarly, whilst the prospect of reversing the international brain drain is very positive, there are concerns that medical tourism will cause an internal brain drain, with health professionals leaving the public health system to work for the hospitals that attract medical tourists.
159. Research is needed on the economic impact for source and destination countries, particularly those low- and middle-income countries where there is speculation but little evidence about the impact of medical tourism treatments on local citizens, either in a health sense or indeed an economic sense. Country case studies of such state-driven support for medical tourism would be a useful starting point to better understand the positive and negative impacts on country finances and populations of involvement with medical tourism.
Organisation and clinical issues
160. In terms of management of services and treatments, there are continuing questions about the range of information and its quality. Given the role of the internet, how (if at all) the quality of medical tourism information is best addressed is unclear: ranging from codes of conduct, through quality labels, user guidance tool, third-party quality and accreditation labels, to educating users and assisting those wishing to search (Lunt et al., 2010). Frontier medicine and the marketing of biotechnologies present a particular issue (Murdoch and Scott, 2010) given that such treatments may not be based on proven clinical trials.
161. A number of business models (e.g. brokers, ownership forms) are emerging within medical tourism. These should be better documented and understood, including their strengths and drawbacks, as well as the implications for managing quality, safety and risk. The relations of emerging business models (e.g. partnership, multinational providers) and patterns and trends of accreditation require investigation.
162. The roles and responsibilities of clinicians and healthcare providers within both provider countries and countries of origin, and organisations responsible for credentialing and continuing professional development of clinicians in provider countries, require clarification regarding their duties in relation to patients who seek help and advice in advance of engaging in medical tourism. What is the role of informing, persuading and advocating for individuals that intend to travel abroad, and the role on return?
What about the public health dimensions, such as pre-travel vaccination, anti-malarial prophylaxis etc.?
How may publicly-funded providers and professional associations be involved? Should clinical ethics committees with lay membership have a greater role?
163. At the clinical interface the normal continuum of care may be interrupted. Full medical documentation, both pre and post-treatment, is crucial in order to minimise risk. In the UK, signed informed consent prior to an elective procedure is considered best practice and a standard requirement ensuring that patients are fully informed as to the benefits and adverse effects of a procedure or treatment.
Patient-clinician dialogue may be problematic given language and distance, and treatment decisions may be unduly influenced by patients having already arrived in the destination country for pre-treatment consultation. Relatively little is known about readmission, morbidity and mortality following self-funded medical treatment abroad. Within treatment speciality there is a need to link together reports of adverse infection control or sub-optimal outcomes. Any legal cases that are pursued should also be documented so that it is possible to build national and international understanding of the implications of trade in health services.
Summary
164. The central conclusion from this review is that there is a grave lack of systematic data concerning health services trade, both overall and at a disaggregated level in terms of individual modes of delivery, and of specific countries. This is both in terms of the trade itself, as well as its implications. For instance, there is little robust evidence that medical tourism adds especially to the economies of destination countries, as figures tend to be quoted in aggregate, but not at the marginal level of the additional tourist-related income specifically resulting from medical tourism. This review has also touched upon overarching legal and ethical considerations surrounding medical tourism. Prior to considering any regulation we need more information and understanding (cf. Smith et al., 2009a).
165. Research and evaluation has not kept pace with the development of medical tourism and there is a need for national governments and potentially international bodies (e.g. EU, OECD, WHO) to invest in research this area. To this end, the UK National Institute for Health Research has recently commissioned research on the implications for the NHS of inward and outward medical tourism and it is hoped that the evidence generated from this study will help inform the development of future policy and practice in this area (Lunt et al., 2011).
166. The lack of data is significant if countries are to keep fully informed about the significance (potential or actual) of medical tourism for their health systems. Mechanisms are needed that help us track the balance of trade around medical tourism on a regular basis. The evidence base is scant to enable us to assess who benefits and who loses out at the level of system, programme, organisation and treatment. On balance there is a pressing need to explore further as to whether medical tourism is virus, symptom, or cure.
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